Assessment for Psychotherapy : Choice of therapy modality and exclusion Criteria. Some Central Questions.

There are four central questions around which assessment for psychotherapy is organized:

1. Are these problems issues which could be addressed by psychotherapy (as opposed to another form of help, such as financial aid)?

2. If these are therapy-accessible problems, what kind of intervention is appropriate?

3. Are there warning signals which suggest that some kinds of therapy might be altogether contra-indicated?

4. What can be predicted about the course and outcome of the therapy chosen?

When psychodynamic therapy is the chosen modality

There are forms of individual psychotherapy which are perhaps best described as `supportive', in the sense that they provide time for reflection and problem-solving without demanding an exploration of unconscious conflict and the defences against this. Cognitive therapy or behaviour therapy are good examples of this. Supportive psychotherapy tends to be time-limited and focussed on an explicit set of difficulties. Regular appointments are desirable but are not necessarily scheduled on a weekly basis. It also tends to be structured, with the therapist as an active presence in setting goals and tasks, suggesting ways to tackle problem situations, and so on. A supportive therapist is not a blank screen.

In contrast to this, psychodynamic work is explicitly directed at unconscious conflict and defensive structures. Weekly appointments are essential, and in many such therapies twice-weekly appointments are preferable to once-weekly ones. Although the therapy may be focussed on a fairly circumscribed problem, to be addressed within an agreed time-frame, it is inevitable that the interpretive work produces conscious and unconscious material about many other issues. The therapy hour is not structured by the therapist, who listens to whatever the client brings to the therapy, and comments, clarifies and interprets, without giving advice or reassurance. Links between past and present patterns of behaviour, connections between anxieties and the defences they provoke, and transference phenomena in relation to both past and present are the focus of attention.

It would be wrong to imply that supportive therapy does not involve unconscious communication, which is present in all interactions, wherever they take place. Moreover, transference and countertransference is also an important feature of all psychotherapeutic encounters. However, in supportive work, the unconscious/transference may structure the interaction, but will not be an explicit focus of interpretive work.

Psychodynamic psychotherapy is hard work for clients. It often intensifies symptoms in the short-term, it heightens anxiety, and it demands considerable tolerance for ambiguity. It is also primarily a verbal medium, and the ability to articulate problems in language is an important (although not essential) skill. The extent to which the client is in touch with feelings is also an issue. Clients unable to bring feelings to the therapy are often better suited to more structured, supportive work. Given the necessarily anxiety-provoking quality of psychodynamic work, clients being assessed to undertake it should be motivated to explore the roots of their difficulties, be psychologically curious, be willing to immerse themselves in an introspective journey, and be able to tolerate the intimacy of the therapeutic relationship.

Psychiatric diagnosis is a major issue in deciding whether someone is suited to psychodynamic psychotherapy. Years of research have mapped out which categories of diagnosis are amenable to work of this kind. There are also some well-established warning bells, summarized below.

Hildebrand's exclusion criteria

Peter Hildebrand, an experienced analyst doing short-term psychodynamic psychotherapy, has suggested the following `exclusion' criteria:

Serious suicidal attempts
Chronic alcohol or drug addiction
Long-term hospitalization
More than one course of ECT
A confirmed homosexual asking to be made heterosexual
Chronically incapacitating phobic symptoms
Chronically incapacitating obsessional symptoms
Gross destructive or self-destructive acting-out

While any one of these in a client's history should prompt the therapist to be very cautious, it must be noted that experienced therapists have frequently found themselves working with `unworkable' clients, often with surprising results. The exclusion criteria are a guide, invaluable to beginners, who have yet to get the `feel' of which problems/clients they might be able to work with.

Assessment for Psychotherapy : Case vignettes

Michael K, a 36 year old mechanical engineer, working for a large construction company, and living with his girlfriend in a large apartment in Rosebank, referred himself for psychotherapy, following a two-week period during which he'd felt confused, anxious, and unable to concentrate on his work. The anxiety had abated a little, but he was still bothered by `clouds of cotton wool in his head'. He was finding it hard to work, and was spending long periods at home, drinking beer and listening to music. He was also smoking dagga every day, mostly alone, but occasionally with friends.

An exploration of Michael's current state in the first interview left the therapist feeling unsure of the exact nature of his problems. He talked readily but the substance of what he said was difficult to grasp. An exploration of his family and personal history was equally unhelpful in pinpointing his problems. He was the oldest of three boys, in a middle-class Cape Town family. He reported his family to be `ordinary' and his relationships with both siblings and parents `not an issue'. He had done well at school, had been good at sport, and had always had friends. He had never been depressed or particularly anxious before.

Michael had been with Sue, his girlfriend, for over a year. She was a buyer for Woolworths, and he had met her at a windsurfing competition in which they were both participating. He had never been in a close relationship before, and said he felt the relationship was `normal', having `ordinary' ups and downs. He said Sue wanted to marry him, but he wanted time to think first.

An exploration of Michael's `confusion' revealed that he had spent hours at a time staring at his computer screen unable to read the words and numbers, and that when driving he would forget where he was going. At night he would become `uneasy', and `plagued by shadows'. Asked whether he had ever been confused in this way before, Michael said he had had such episodes, but they had never been as intense. He was unsure of what had precipitated his confusion on this occasion. Work was going well, and his relationship with his girlfriend was peaceful and supportive. However, Sue was putting some pressure on him to make up his mind about marrying, and there had been one major argument, during which he'd been angry and had banged his fist against the wall.

Mary J, a 30 year old librarian, reported herself to be depressed, tired and constantly fretful. She had been taking anti-depressant medication, but although this helped her to sleep, it had failed to alleviate her `utter misery'. She had contemplated suicide, and was spending hours each day lying on her bed doing nothing. She was not seeing friends or her invalid mother. She said her cat was `the only creature she felt like talking to'.

Mary had had several periods of severe depression before, and had been in therapy twice previously. Neither of her previous therapists had `understood' her misery or `taken her seriously'. She had made two attempts at suicide, once slicing her wrists in the bath, and another time taking a large overdose of anti-depressants. Both times had precipitated brief hospitalization.

Mary was the youngest of four children. Her father had been alcoholic and when drunk had regularly beaten her mother, sometimes severely enough to necessitate treatment in hospital. He had died five years previously in a car accident. Her mother was asthmatic and also had a weak heart. She had always been in poor health, and Mary reported that the household had mostly been run by her oldest sister, now living far away.

Mary had never been in a close relationship, and disliked the idea of any sexual contact. She said her father had raped her mother many times when drunk, often in front of the children, and this had made her hate men and sex.

Peter J, a 40 year old taxi driver, came to therapy at the request of his wife, who said she was leaving him unless he did something about himself. He said she felt he was unable to be affectionate, and found his `quietness' and withdrawn manner of relating a problem. She said `it's like living with a statue or a corpse'. She also resented Peter's long work hours. An additional source of stress for both of them was the violence and uncertainty of the taxi business.

Peter said he'd always been a quiet man, preferring to think things through in his head, not `chattering like a girl'. His father was also quiet. He said he was happy in his marriage, and would like to save it, and this was why he'd come to see the therapist.

Jessica P, a 30 year old doctor, working in a busy local hospital's casualty department, sought therapy because she had a pattern of ending relationships with men a few months after they had begun. The relationships would begin well, but Jessica would gradually become irritated with mannerisms, habits or ways of talking. She would then end the relationship abruptly, leaving the man concerned at sea about what had happened. These men frequently remained extremely attached to Jessica, and continued to phone her, begging for a reconciliation. She found this very difficult, and often was trapped into trying to console them, sometimes over periods of months.

Jessica had two siblings, one a year younger, and one three years younger. She had been `mamma's helper' at home, the `good' child, propping up an over-extended and anxious mother. Her father had died when she was six, and she barely remembered him. She had been told that he was gentle, loving and a `perfect' father.

In the first interview, Jessica was brisk, matter-of-fact and aloof as she talked about her problem. She questioned the therapist closely about her theoretical orientation, expected frequency of sessions, and length of time needed to `talk this out'. At the end of the session she struggled to settle on a time for a regular appointment, saying that her schedule was so full that no reliably-free time was available. An appointment was made for the following week, and it was agreed that they would discuss Jessica's schedule again at that point. Jessica said, `I'm sure you are as busy as I am. You must have patients needing you more urgently than me.'

Sally Swartz